CA-5B Claim for Compensation by Parents, Brothers, Sisters, Gr

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U.S. Department of Labor

Claim for Compensation by Parents,
Brothers, Sisters, Grandparents, or
Grandchildren

Employment Standards Administration
Office of Workers' Compensation Programs
OMB No. 1215-0155
Expires: 05-31-2007
2. Date of Birth
(Mo., day, year)

1. Name of deceased employee (Last, first, middle)

4. Date of Death
(Mo., day, year)

5. Social Security Number

7. Nature of injury which caused death

6. Name and address of employing agency (Include ZIP Code)

10. Dependent's birth date
(Mo., day, year)

9. Dependent's address (Include ZIP Code)

8. Name of dependent (Last, first, middle)

12. Dependent's Social
Security Number

11. Dependent's Occupation

3. Date of Injury
(Mo., day, year)

14. Extent of dependency on
employee

13. Dependent's relationship to
employee

Total
16. Did employee live with
dependent during the 12
months immediately prior
to death?
Yes
No
$
If ''Yes'', Complete 17 & 18.
19. If dependent was employed during 12 month period prior to
employee's death, give:
15. Total amount employee
contributed to dependent's
support during 12 months
immediately prior to death.

Per

Investments

Period of employment:

Pensions

Monthly pay rate:

Persons other than employee

Name and address of employer:

Other

$

Total

$

23. Monthly pay rate

24. Total income from all sources for
12 months prior to employee's
death.
$

$
25. List all property owned by dependent and husband or wife (omit clothing, furniture, personal items).

Description

Date Acquired

26. If an application has been made for U.S. Civil Service Annuity or any
other Federal Retirement or Disability Law because of employee's
death, give:
Retirement System:

CSRS

FERS

SSA

b.

Date each benefit began:

29. Total burial expense
$

Value

27. If an application has been made for Veterans Administration (VA)
benefits because of employee's death, give:
VA Claim number:

Service number:

Address of VA office where claim is filed:

a.

Claim number for each claim:

Amount of each benefit paid per month:

Other

Per

$

20. Show dependent's income from all sources other than employment
during 12 month period prior to employee's death:

Type of work performed:

Information about dependent's husband or wife (Items 21 through 25)
21. Birth Date (Mo., day, year)
22. Occupation

18. If no fixed amount was paid
for room and board, what is
the fair value of such room
and board?

17. Total amount employee paid
dependent in money or service
for room and board in addition to
amount shown in 15.
$

Partial

$

28. If a claim has been made against a third party because of employee's death,
give:

a.

Amount of recovery:

b.

Name and address of third party:

$

a.
b.

30. Amount of burial expense paid 31. Name and address of party (other than VA) whose funds were used to pay burial expense
or payable by VA
and amount paid:
$

$

I hereby certify that each and every statement made 9 above is true to the best of my knowledge. Any person who knowingly
makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain compensation as
provided by the FECA or who knowingly accepts compensation to which that person is not entitled is subject to felony
criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both.
32. Signature of person filing claim

33. Address (Include ZIP Code)

34. Date
(Mo., day, year)
Form CA-5b
Rev. Jan. 1997

Attending Physician's Report
1. Name of deceased employee (Last, first, middle)

2. Date of death (Mo., day, year)
4. If treated for disease, give diagnosis.

3. What history of injury or employment related disease was given to you?

6. Show dates on which treatment
was given.

5. If death was not instantaneous, describe the treatment you provided.

7. What was the direct cause of death?

8. What were the contributory causes of death, if any?

9. In your opinion, was the death of the employee due to the injury as reported in item 3 above?
Give the medical reasons for your opinion, unless causal relationship is obvious.

10. Was a biopsy or an autopsy performed?
Arrange for a copy of the report to be submitted.

Yes

Yes

No

No

11. Name and address (Please type - include ZIP Code)

I certify that all statements in response to the questions asked above are true, complete and correct to the best of my knowledge.
Further, I understand that any knowingly false or misleading statement or concealment of material fact may subject me to felony
criminal prosecution.
12. Signature

13. Date signed (Mo., day, year)

INSTRUCTIONS FOR COMPLETING FORM CA-5b, CLAIM FOR COMPENSATION
BY PARENTS, BROTHERS, SISTERS, GRANDPARENTS OR GRANDCHILDREN

Who Should
File Claim

This claim form should be completed and filed by the deceased employee's parents,
grandparents or representative (custodian or guardian) of minor brothers, sisters or
grandchildren. A separate form is required for each person claiming benefits.

When Should
Claim Be Filed

Claim must be filed within three years following date of death, unless the
decedent's immediate superior had actual knowledge of an on-the-job injury or
death within 30 days; or written notice of the injury or death was given within 30
days. The timely filing of a disability claim will satisfy the time requirements for a
death claim based on the same injury.

What Documents
Are Required

The birth certificate of the deceased employee; also a death certificate if not previously submitted; birth certificates for minor brothers, sisters and grandchildren. If
claim is made on behalf of a grandparent, birth certificate of decedent's mother or
father, as appropriate. If claim is made on behalf of a grandchild, birth certificate of
decedent's son or daughter as appropriate. Copies of certificates or documents are
acceptable only if they are certified by the person having official custody of such
records. They should then be attached to the claim form when it is filed.

How to
Complete Claim

All items on the claim form should be completed. If an item is not applicable, indicate by
showing "NA". Note that the claim form requests information about several categories of
persons, i.e., items 1-7 make inquiry about the decedent; 8-20 the dependent; 21-25 the
dependent's husband or wife, if married at the time of employee's death. The attending
physician's report on the reverse of the form must also be completed before the form is
is submitted to the OWCP.

Funeral/Burial
Allowance

Submit original itemized funeral and burial bills. If paid, so indicate and give name and
address of person making payment. if an Administrator or Executor has been
appointed, give such person's name and address and attach a copy of the appointment
document.

See the reverse of this page for a definition of dependents and a description of benefits.

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Worker's Compensation Programs, U.S. Department of Labor, Room S-3229, 200 Constitution Avenue,
N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402

DEATH BENEFITS FOR PARENTS, BROTHERS, SISTERS, GRANDPARENTS
AND GRANDCHILDREN UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)
Eligible
Dependents

l Benefits are payable on behalf of partially or totally dependent parents, brothers, sisters,
grandparents and grandchildren.

Period Of
Entitlement

l Parents and grandparents: Payments continue until death, remarriage or termination of
dependency.
Minor brothers, sisters and grandchildren: Payments continue until death, marriage or
attainment of 18 years of age. Payments may continue beyond 18 if the child is mentally or
physically incapable of self-support or is a "full-time" student. Student benefits terminate on:
marriage, completion of 4 years of education beyond high school level, or at age 23,
whichever occurs first.

Compensation
Rates

l For parent - 25% of the employee's monthly pay, if one is wholly dependent and the other is
not dependent at all. If both are wholly dependent - 20% each. A proportionate amount is
paid if either or both are partially dependent.
Brothers, sisters, grandparents, and grandchildren - 20% if only one is wholly dependent. If
more than one is wholly dependent - 30% shared equally. If one or more is partially dependent
- 10% shared equally if more than one.
Federal payments are made through Direct Deposit. Therefore a completed Form SF-1199A,
Direct Deposit Sign-up must be submitted with Form CA-5b.
If the employee was covered under the Federal Employees's Retirement System (FERS), 5
USC 811 (d)(2) requires that Social Security benefits payable to beneficiaries, which are
attributable to the deceased employee's Federal Service, are deducted from the beneficiary's
compensation entitlement.

Payment
Priorities

l Monthly payments for all beneficiaries cannot exceed 75% of the employee's monthly
salary or 75% of the top step of GS-15 of the General Schedule. The surviving widow or
widower and children have first priority. Other eligible dependents may receive payment only if
the widow or widower and children's percentages are less than 75%.

Funeral/Burial
Allowance

l Funeral and burial expense up to a maximum of $800 may be paid. Amount paid by
the VA will be deducted. If death occurs away from the employee's duty station,
transportation costs may be paid to return the deceased employee to his home or
last place of residence. In addition to any funeral or burial expenses, a sum of $200
may be paid for reimbursement of the costs of termination of the decedent's status
as an employee of the United States.

Third Party
Action

l If the employee's death was caused by a person or party other than the Federal
Government, a ''third party action'' or lawsuit may be indicated. In such instances the
Department of Labor will provide further instructions.

Privacy Act Notice
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation
Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)
Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be
verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the
claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to
consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other
government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services.
(5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational
rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may
be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to
determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to
pursue salary/adminsitrative offset and debt collection actions required or permiotted by the FECA and/or the Debt Collection Act. (7)
Disclosure of the claimaint's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and
other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal
govoenrment, and for other purposes required or authorized by law. (8) Failure to disclose all requested ifnormation may delay the processing
of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the
processing and adjudication of the claim you filed under the FECA.
Public Burden Statement
Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S-3229, 200 Constitution Avenue,
N.W., Washington, D.C. 20210.
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402